Jail-Based Syphilis Services Can Benefit Both Arrestees And the Larger Community

Programs offering routine testing and treatment for syphilis in jails can help prevent transmission of the disease by identifying infected individuals and treating them before they return to the community, a study conducted in Louisiana demonstrates.1 One percent of arrestees who were tested for syphilis upon entering a parish jail between 1994 and 1998--nearly 500 individuals--were found to have a previously undetected infection, and 61% of these men and women received treatment while incarcerated. Trends in prevalence over the study period were similar to those in the surrounding community, suggesting that jail-based programs could be a means for monitoring community-level infection rates.

The program, designed as a response to a statewide syphilis epidemic, was launched in 1994 at the jail serving the metropolitan Baton Rouge area. Participation is not required, but arrestees are offered the opportunity to be tested for syphilis within 24 hours of their arrival at the facility; likewise, treatment is offered to infected individuals, but is not mandatory. Researchers analyzed program data for the period from July 1994 through December 1998 to assess the program's effectiveness in detecting untreated cases of syphilis and its value to community-level surveillance, as well as to examine the population at greatest risk of infection.

During the study period, more than 50,000 men and women were booked into the jail; 76% underwent syphilis testing. Most of those who were not tested either refused or were freed on bond before the test could be administered. Arrestees who were tested were predominantly male (84%) and black (73%), with a median age of 29 years. In all, 494 cases of syphilis were detected among individuals who had no history of the disease, for an overall prevalence rate of 1.3% among those tested. Prevalence was more than twice as high among women and black arrestees as among men and whites (odds ratios, 2.4 and 2.6, respectively); it rose as arrestees' age increased. Sixty-one percent of infected individuals were treated before release; those who did not receive treatment in jail were followed up by disease intervention specialists to ensure that they obtained treatment once they returned to the community.

Over the course of the study, the prevalence of early syphilis (defined as primary, secondary or early-latent infection) declined by 68%. At the same time, the prevalence in East Baton Rouge Parish, as reported by laboratories and health care providers, fell by 79%. (Cases of early syphilis identified in the jail program made up a substantial proportion of those in the community overall--between 15% and 31% each year between 1995 and 1998.) The researchers note that the prevalence monitoring data from the program are less likely than the case-reported data from the parish to be biased by underreporting, and they therefore conclude that "in areas where case reporting is weak and jail screening coverage high, monitoring prevalence among arrestees can be a useful way to monitor syphilis trends independently of other [disease] control program activities."

Using data on 125 arrestees in whom early syphilis was diagnosed in 1995-1997 and 385 uninfected controls, the researchers examined the characteristics associated with syphilis in this jail population. The findings indicated that among women, those who had syphilis were significantly more likely than controls to have been arrested for prostitution (odds ratio, 7.0). Among men, a syphilis diagnosis was associated with increased odds of felony theft (4.3). No other charges (including possession of substances and previous incarceration) were associated with syphilis risk, and these two accounted for only small proportions of infected individuals (13% of females and 12% of males). Therefore, the investigators observe, cause of arrest is not a valid criterion for determining whom to screen for the disease in jail-based programs.

The researchers conclude that jail-based programs are useful as public health interventions and as tools for monitoring disease trends. Noting that "serologic screening has been a cornerstone of syphilis control in the United States," they recommend that control strategies involve "targeted serologic screening programs" not only in jails, but also in other community-based settings, such as drug treatment centers and emergency rooms.--D. Hollander